Falls: Preventing a Downward Course Thru Assessment of the Geriatric Patient

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Falls Preventing a Downward CourseThru
Assessment of the Geriatric Patient

• Paula Bordelon, DO

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Disclosure

• No conflicts of interest
• No financial relationships with pharmaceuticals
  to disclosure

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Objectives

• Teach a systematic approach to assessment of gait
  and balance
• Highlight abnormalities commonly seen in elderly
• Increase knowledge STEADI toolkit
• Review AGSs fall guidelines

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Case History

• 78-year old female scheduled with you to
  establish care.
• Presents with her daughter.
• Lives alone and uses no assistive devices.
• Dtr reports 1 fall mom slipped
• Dtr reports occasional dizziness and balance
  issues. Patient states Im fine

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Case History (cont)

• Meds HCTZ, glyburide, ASA, temazepam prn
• DEXA osteoporosis of femoral neck
• Did your new patient fall?
• Does your new patient need specific intervention
  to prevent falls?

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Falls Affect Morbidity and Mortality

• Falls should not be viewed as normal aging!
• Overall nonfatal fall injury rate was 43/100,000
  falls (based on those seeking care)
• 1 out of 3 seniors fall but lt 50 report this
• Among seniors falls are leading cause of fatal
  and nonfatal injuries
• 1 in 5 falls cause serious injury

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Falls the Facts

• Falls are common
• About 35 of community-dwelling ages 65-69 fall
• gt 50 of community-dwelling gt age 80 fall
• 95 of hip fractures are caused by falls
• FALLS CAUSE POOR OUTCOMES!
• Death rate from falls has risen sharply over past
  decade (64 men 84 women)

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Fall Prevention is Paramount

• Falls are a MAJOR health hazard, up to 30 who
  fall suffer injuries, lacerations, hip fractures,
  head trauma
• Functional deterioration after falls is common
  and often leads to institutionalization
• Of those who fall, only 50 can arise without
  assist
• Falls are the most common cause of traumatic
  brain injuries in seniors
• 75 of fall-related deaths occur in those gt age 65

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The Most Costly Fall Hip Fractures

• Hip fractures are the most costly injuries in
  terms of mortality, health, reduced quality of
  life, and admission into nursing home
• Recover more slowly
• More adverse consequences post-op
• 33 of hip fracture survivors spend at least one
  year in SNF
• 20 of seniors hospitalized for hip fracture die
  within 1 year

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What is a fall?

• Any incident that involves unintentionally coming
  to some lower level (or to the ground) is a fall.
• Older adults frequently have incidents that meet
  the definition of a fall, but deny falling
• Slipping, tripping, stumbling or tumbling.

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Who is at Risk?

• Intrinsic Factors
• Advanced age
• Cognitive Impairment
• Sensory Impairment (e.g. decreased vision)
• LE weakness
• Poor mobility

• Extrinsic Factor
• Medications
• Polypharmacy (gt 4)
• Psychoactive
• Inactivity
• Environmental

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Who Should Be Screened?

• Anyone age 65 and over should be screened (that
  is, asked if they have fallen IN THE PAST YEAR!)
• Alternative Have patient answer CDCs risk
  factor (12 question) screening

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Screening (cont)

• Anyone senior who has fallen, feels unsteady, or
  a fear of falling, should be evaluated for gait
  and balance
• If senior performs poorly on evaluation, should
  undergo multifactorial fall risk assessment

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How Do You Screen?

• Simply use questionnaire from STEADI toolkit or
• Inquire about history of falls
• Have you slipped, tripped, stumbled, or fallen in
  the last 6 weeks? In the last 12 months?
• Do you feel unsteady when standing or walking?
• Are you fearful about falling?

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How Do You Screen? (cont.)

• For yes responses, inquire as to frequency,
  circumstances, and if have difficulty with
  balance. Getting an accurate history gives you
  info to prescribe the best plan

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How Do We Balance?

• Balance via dynamic input
• Vision
• Inner Ear (vestibular)
• Proprioceptive Sensing
• Strength and flexibility

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How Does Aging Affect Balance?

• Successful fall prevention begins with knowledge
  of age-related changes
• Vision - reduction in glare tolerance, nocturnal
  acuity, contrast sensitivity, reduction in
  peripheral vision and poor depth perception

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How Does Aging Affect Balance?

• Vestibular - peripheral vestibular excitability
  declines with age while vestibular dysfunction
  (e.g. BPPV, Menieres) increases, with loss of
  hair cells and ganglion cells, contributing to
  falling
• Proprioception - reduced function occurs in many
  d/o (e.g. DM, Etoh, malnutrition, cervical
  spondylosis)

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Centers for Disease Control American Geriatrics
Society

• CDC www.CDC.gov/homeandrecreationalsafety/falls/ST
  EADI
• AGS www.americangeriatrics.org/health_care_profes
  sionals/clinical_practice/clinical_guidelines_reco
  mmendations/prevention_of_falls_summary_of_recomme
  ndations

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Key Components of Fall HISTORY

• Get History Get description of the circumstances
  of the fall frequency, symptoms at time of fall,
  injuries (TARGET INTERVENTIONS)
• Review Meds All prescribed and over-the-counter
  medications with dosages
• Obtain History of relevant risk factors Acute or
  chronic medical problems, (e.g., osteoporosis,
  urinary incontinence)

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Key Components of PHYSICAL Evaluation

• 1. Lower Extremity Muscle Strength
• 2. Exam feet footwear
• 3. Neurologic (cognitive eval, proprioception,
  peripheral nerves, reflexes, cerebellar function)
• 4. Visual acuity (when to consider monocular)
• 5. HR, rhythm, BP, check orthostatics

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Components of FUNCTIONAL ASSESSMENT

• Assess ADL, including ability to use assistive
  devices and adaptive equipment
• Assess for fear of falling and perceived
  functional abilities and health

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Post-fall Syndrome

• Is a phobic response to the discordant and
  inaccurate sensory inputs
• Creates a self-perpetuating cycle of increasing
  weakness and instability via joint mobility
  reductions, physical deconditioning, and poor
  balance
• Loss of self-confidence to ambulate can result in
  self-imposed limitations

Source Journal of Rehabilitation Research and
Development 40 (1) January/February 2003 49-58.
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Exam of Lower Extremities

• Search for mechanical problems-orthopaedic,
  vascular, podiatric, rheumatic
• Examine ROM at hip, knee, ankle
• Palpate for pulses at femoral, popliteal,
  dorsalis pedis, posterior tibial

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Exam of Lower Extremity (cont)

• Muscle Tone (resistance of extension) if
  increased and feet are stuck to the floor ,
  consider NPH or frontal lobe dysfunction

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Neurologic Dysfunction

• Cerebellar Ataxia Cerebellum processes input
  from brain, spinal cord, and sensory receptors to
  provide timing of precise, coordinated movements
  of skeletal muscle system (e.g. limb position).
  With ataxia, have dizziness, imbalance, and
  difficulty coordinating movements

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Neurologic Considerations

• Dizziness and Vestibular Ataxia use inner ear
  (vestibular) and sensory to balance consider an
  etiology for vascular, vestibular, brain stem,
  trauma, or medication problems

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Neurologic Considerations

• Rombergs (standing balance with eyes closed)
  presence means sensory deficit (abnormality of
  proprioception) in peripheral vestibular,
  peripheral neuropathy, decreased position sense
  (dorsal column) if due to neuropathy, ankle
  jerks will be absent if a spinal cord issue,
  Babinski will be present
• Treatment improve lighting, use assistive
  devices, good footwear

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Neurologic Considerations

• Cerebellar signs presents with incoordination,
  ataxia, unsteadiness with eyes open. If
  positive, determine rapidity of onset. Acute
  posterior fossa stroke Subacute mass,
  demyelinating or degenerative processes,
  metabolic disorder, or drug effect
• Treatment assistive devices, reduce clutter,
  gait training

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Neurologic Considerations

• Sternal nudge with staggering or becoming
  unstable, consider neurologic or back disease
• Treatment remove clutter, prescribe assistive
  devices, avoid slippers or loose-fitting shoes

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Neurologic Considerations

• Unstable with turns with instability, consider
  cerebellar, reduced proprioception, hemiparesis,
  or visual field cut
• Treatment gait training, prescribe assistive
  devices, proper fitting shoes, reducing obstacles

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Functional Examination

• Evaluate patients gait. Note symmetry, speed,
  and ability to walk in a straight line/path
  undeviating.
• Is center of gravity altered? (Wide-based?)
• Look for hesitation with turns when pivoting.
• Note if good arm swing and if there is sound
  distance between floor and soles of feet.

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Functional Evaluation of Gait Timed Up and Go
(TUG) per STEADI

• TUG should be able to execute in lt 13 seconds
• Difficulty of arising from chair suggests
  proximal muscle weakness, arthritis, or
  neurologic disease
• Treatment portable seat lift, muscle
  strengthening exercises, increase functional
  mobility, treat specific illness

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Functional Examination 4-Stage Balance Test
per STEADI

• Test stance Side-by-side, semi-tandem, tandem
  stances, and balancing one foot.
• If cannot perform side-by-side, semi-tandem, or
  tandem stances, senior is at increased risk

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Functional Exam One Opinion

• Failing
• Side-by-side if fail, need walker and PT
• Semi-tandem if break early, need walker and PT
  mid-break, need cane late break, order balance
  (e.g. Tai Chi) and exercise classes
• Tandem balance and exercise classes
• my personal opinion

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Functional Examination 30-second Chair Stand
per STEADI

• Results are based on sex and age and grid that
  details Below Average Scores
• If patient scores are below average, he is at
  risk for falling and needs intervention

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Other Aspects of Examination

• Psychiatric
• Brief screen for cognitive functioning
• Brief screen for mood (depression)
• Assess for fear of falling Do you have a fear
  of falling? If yes, does your fear decrease your
  activity level?

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Appliances Recommended to Reduce Morbidity and
Mortality

• Reachers
• Portable seat lift
• Special step stools
• Hip protectors (controversial, falling in and out
  of favor)

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Interventions for Community Dwellers According
to AGS

• Adaptation/modification of home environment A
• Withdrawal/minimization of psychoactive
  medications B
• Withdrawal/minimization other medications C
• Management of postural hypotension C
• Management of foot problems and footwear C
• Exercise, particularly balance, strength, and
  gait training A

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Strength of Recommendation Rating System

• A A strong recommendation that the clinicians
  provide the intervention to eligible patients.
• Good evidence was found that the intervention
  improves health outcomes and the conclusion is
  that benefits substantially outweigh harm.
• B A recommendation that clinicians provide
  this intervention to eligible patients.
• At least fair evidence was found that the
  intervention improves health outcomes and the
  conclusion is that benefits outweigh harm.
• C No recommendation for or against the
  routine provision of the intervention is made.
• At least fair evidence was found that the
  intervention can improve health outcomes, but the
  balance of benefits and harms is too close to
  justify a general recommendation.

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Strength of Recommendation Rating System

• D Recommendation is made against routinely
  providing the intervention to asymptomatic
  patients.
• At least fair evidence was found that the
  intervention is ineffective or that harm
  outweighs benefits.
• I Evidence is insufficient to recommend for
  or against routinely providing the intervention.
• Evidence that the intervention is lacking, or of
  poor quality, or conflicting, and the balance of
  benefits and harms cannot be determined.

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Quick Tips

• Studies demonstrate that Vitamin D
  supplementation (800 IU/day) reduces falls
• Patients using monocular (single vision) vision
  glasses when performing activities and walking
  are less likely to fall

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The Bottom Line

• Falls are treatable geriatric syndrome
• Screening for falls begins with one question
• Falls can be reduced by up to 40 with
  intervention
• Medicare typically covers services needed to
  treat patients risk factors

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Conclusion

• Falls are complex and multifactorial
• Marker of frailty
• What predisposes persons to falling often
  produces observable disturbances in gait and
  balanceso assess in office
• Interventions most likely to prevent injury are
  exercise and environmental modification